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First Aid for Mentally Ill or Emotionally Disturbed Persons

Written by Liz Boardman

In the past two years, three mentally ill men have been killed and one critically injured after struggles with police in Rhode Island. “There have been a few unfortunate police contacts with people with mental disorders,” said Lieutenant Joseph Coffee of the Warwick, R.I. Police Department, one of the instructors of Mental Health First Aid. This is a training program that teaches officers strategies for recognizing and responding to mental illness.

“We did not want to perpetuate the stigma that the mentally ill are crazy and dangerous, but to stress the procedure and protocol in responding. Officers have to consider the facts and circumstances, and consider mental health as a factor in the totality of the circumstances,” he said.

Mental Health First Aid is offered by the Rhode Island Municipal Police Academy and Gateway Healthcare, based in Pawtucket, R.I. It was adapted for police, campus police, security and dispatch personnel from a 12-hour Australian program for civilians who want to learn how to support someone in a mental health crisis.

Mental Health First Aid does not make officers “curbside psychologists,” Coffee said, nor is this hostage negotiation training. Instead, it helps officers determine if a mental illness may exist so they can adjust their response, if the situation allows. Coffee said the program was created because in many communities, officers are the only 24/7 emergency responders. There is already evidence that the training works.

In August 2009, Providence police officers arrived to a call to find a 250-pound, 12-year-old boy, who turned out to be autistic, wearing only shorts, and with duct tape around his neck and feet, using a large kitchen knife to stab holes in an elderly woman’s screen porch.

Lieutenant Daniel Gannon, 7th District commander for the Providence Police Department, credits Mental Health First Aid with giving him the skills to defuse the situation peacefully. Gannon did not know the 12-year-old boy was autistic and had obsessive-compulsive disorder until the boy’s mother arrived at the scene. But the clothes, the duct tape and the boy’s flat responses led him to think mental illness was a possibility.

“When I see something that seems off, I take an extra minute to think,” Gannon said. “We had all the time in the world, so long as nobody was hurt. A lot of it is common sense and not jumping into action too quickly. If you can take the time, take it.”

On the porch, the boy was cutting the screen but was not otherwise acting in an aggressive manner, Gannon said. When he ignored commands to drop the knife and began advancing on them, Gannon and his fellow officers did not draw their guns and TASERs. Instead, Gannon created distance by picking up a lawn chair and holding it between him and the boy. This technique was less threatening than a gun or a TASER but offered a protective block had the boy charged Gannon. The officer used a calm voice and reassuring language like, “It’s too hot for this. Let’s go get a lemonade.”

For Gannon, Mental Health First Aid training got him through a tense 15 minutes, after which the boy dropped the knife and was persuaded to be evaluated at the hospital. He was not charged. “There are a lot of people like him who are getting arrested who shouldn’t be,” Gannon said. “It serves no purpose.”

What the Training Teaches

The first step of the training is learning the signs of mental illnesses. Depression often presents itself as someone who is moving and thinking slowly. The person usually looks sad, anxious and irritable, though in severe depression the person’s emotions may be blunted. When they speak, they tend to use language that is negative about themselves, the world and the future, like “Nothing good ever happens to me,” or “Things will always be bad.”

Anxiety disorders can manifest in physical ways, like chest pain, hyperventilation, vomiting or tremors. It can also show psychologically, through excessive worrying, indecisiveness, anger and confusion, or behaviorally, with avoidance, or obsessive or compulsive behavior.

Psychotic disorder can appear to be depression and/or anxiety. But people with a developing psychotic disorder are likely to have trouble focusing their attention and may have an altered sense of the world; odd ideas; a lack of grooming; and reduced or heightened senses of smell, sound or color. They may also isolate themselves from others and have difficulty managing work or their home lives.

Next, officers are asked to step into the shoes of someone with schizophrenia so they can understand how overwhelming it can be to hear voices, a hallucination that often occurs with the illness. “We put on a headset that played audio of voices,” Gannon said. “Then we read an article and had to answer questions about it.”

Having the voices barking out random commands while he was trying to concentrate on reading, comprehending the material and responding to questions, woke Gannon up.

“I was amazed by how hard it was,” Gannon said. “I see people every single day at homeless shelters who are alone and talking and laughing.”

“Some officers cannot do it,” said Carole Bernardo, a civilian Mental Health First Aid trainer with Gateway Healthcare. “They take off the headsets.” After experiencing the voices, Gannon could see how having three officers in the room with radios, and two of them talking, could escalate a situation. “We tell them to reduce the barriers and the number of people in the room if it is disruptive and if there is no danger to the officers,” Coffee said.

Throughout the training, officer safety is stressed, but officers are also urged to slow down their speech and actions and wait things out, when the situation allows it. “We may not respond, situation permitting,” Coffee said. “If a person is throwing items in the opposite direction of the officer, they are clearly responding to something the person perceives as a threat, but it is not an immediate threat.”

The officers also learn how to handle people who are exhibiting paranoia or making delusional statements. Paranoid people can appear very tense and be very suspicious of police officers. In such cases, Coffee recommends becoming as non-threatening as possible and allowing the person to feel that he is in control. That means not picking up on verbal challenges, like, “You’re a police officer, you have those secret records on me,” by agreeing with the person’s paranoid statements. Officers should not confirm that they have any special knowledge about the person, Coffee said.

In cases where a subject is making delusional statements, officers learn they should not agree, by making statements such as, “Oh, so the aliens took it,” which can increase the person’s anxiety. Nor should they dispute the delusion, which can make the person withdraw, argue or act aggressively. Instead, officers can defer the issue by acknowledging the person’s world view, while stating that they do not share the view, but understand the person’s feelings.

“There are many people who want me dead,” a subject might say. “There is an organization on TV that had my name on TV.” “I can see you are worried about someone harming you,” the officer could respond. “I don’t know of anybody who wants to hurt you, but I really would like to assist you in any way I can, to help you feel safer.”

Encounters with people with mental illnesses follow the same patterns as other calls for service, Bernardo said. Most will be during the evening shift, with fewer during the day, and fewest during the night shift. This population is most vulnerable in the evening and on weekends and holidays, when their support systems are not in place and mental health agencies may be closed.

Bernardo stressed that the mentally ill may be suspected of a crime or the subject of a call because they are acting inappropriately. But it is as likely they are the victim or witness of a crime or accident, or are reporting “incidents” that are the result of delusions.

They may also be officers, Coffee said, pointing to a recent national study where 26.2 percent of people over 18 reported having at least one mental health problem in the previous year.

“I always ask if there is a person in the room who has a friend or relative or some connection with mental health issues,” Coffee said. “We have officers coming back from the war depressed, and there are certainly officers on [mental health] medications.”

Coffee said the program is an investment in dispelling misconceptions about mental health and taking steps to help, rather than leaving the situation status quo. “Do you want to go back to a house on a mental health call?” he asked. “Today’s depressed person could be a suicidal barricade in three weeks.”

While Gannon and many other officers have found success with the program, Coffee said it is still a hard sell in real-life situations. “An officer goes to the scene trying to think outside the box, but he might have a supervisor who cannot understand what he is doing,” he said.

“The roll call sergeant wants tickets and drug bust arrests. The other officers razz you because you spent extra time with ‘the nut case.’ You aren’t going to get a pat on the back for the way you solved that mental health case, not even from the guy you helped, in many cases. It’s a challenge, and you have to be in it for the right reasons. There are no accolades.”

The community-based version of Mental Health First Aid is offered nationwide. For more information, visit www.gatewayhealth.org/MentalHealth/FirstAid.asp, or www.thenationalcouncil.org/cs/mental_health_first_aid_in_the_us.

Liz Boardman is a reporter and freelance writer based in Wakefield, R.I.